ICU Early Mobilization: Movement, Not Rest, May be Key to Recovery

The Montefiore Early Mobility team assists a comatose ICU patient with physical therapy. The ergonometric motorized recumbent bicycle increases circulation and blood flow, activates the skeletal muscle, and helps restore coordination of the respiratory rate and muscles with the level of activity performed. watch video

BRONX, NY - March 5, 2014 - Recent studies have shown that immobility in ICU patients can result in a number of long-lasting health problems including joint shortening, muscle wasting and weakness, delirium, and an overall inability to regain normal function. Montefiore Medical Center's new interdisciplinary Early Mobility Program has shown promising results in restoring patients' strength and aiding their recovery following episodes of critical illness.

"We used to think that keeping critically ill patients sedated and in bed helped them rest and get better, and that it was expected that these patients will experience weakness and confusion," said Dr. Daniela Levi, Director of Quality, Safety, and Development and the first faculty physician at Montefiore to advocate for early mobilization. "We now know that rehabilitation can help decrease ICU-acquired weakness and delirium, and that under the right conditions critically ill patients can be helped to move safely."

Daniela Levi, MDOther reasons that ICUs have traditionally restricted the mobility of their patients include fear of patient falls and the possibility of disconnecting catheters, artificial airways, and other life-support equipment. However, studies show that patients who are rehabilitated earlier come off their ventilators sooner, leave the ICU and the hospital earlier, and have fewer complications. Portable ventilators and other adaptive equipment enable patients to walk through hospital hallways with their supportive machines safely intact.

"Though some people focus on the risks or difficulty of starting a program, it is key to focus on what is in the patient's best interest," said Dr. Lewis Eisen, Medical Director of the Moses MICU and Associate Professor of Clinical Medicine at Albert Einstein College of Medicine.

The Early Mobility Program, launched in July 2013 in the Moses Campus Medical Intensive Care Unit (MICU), involves a multidisciplinary team including physical and occupational therapists, respiratory therapists, ICU nurses, physicians, and ICU staff assistants. The team members are working together at the same time requiring significant team coordination achieved through complex simulation sessions. The early mobility team has made a drastic improvement in patients' recovery time and the regaining of functional ability, according to Dr. Levi. Seventy to ninety percent of MICU patients receive physical therapy or occupational therapy during their stay (a significant increase from before the program's inception).

A Mobility team member assists an ICU patient in getting out of bed.Therapy begins as early as the patient's first day in the MICU, even in instances where the patient is still unconscious. Activities are tailored according to each patient's state of health, and may include:

turning and sitting in bed

standing and walking with supervision

practicing personal grooming skills

working on patients' activities of daily living (ADLs)

use of an ergonometric motorized recumbent bicycle to mobilize the upper and lower body

Lewis Eisen, MDThe program has provided encouragement for patients and their families, leading to greater cooperation, according to Dr. Eisen. In one instance, a patient and her family were having a great deal of difficulty dealing with her critical illness. The Early Mobility team worked with the patient to help her move out of her bed and sit up in a chair. When the family saw her in this setting, their concern lessened significantly. In turn, the patient's mood and outlook improved, and she became much more engaged in her care.

The Montefiore Early Mobility team assists an ICU patient in getting out of a chair.Another patient, a member of a paramilitary group and a marathon runner, had developed pneumonia from training in extreme heat and was admitted to the ICU with septic shock and respiratory failure. He then developed muscular breakdown, sepsis, kidney failure, and organ shutdown. While the patient was in a medically-induced coma, the early mobility team orchestrated passive range of motion exercises, which enabled him to get out of bed engage in physical therapy soon after he awoke. He eventually regained full physical and cognitive function and returned to his career.

"Usually patients who have this kind of septic shock take months to recover, and their muscle weakness and cognitive impairment can last up to five years. Many never return to their professions or are even able to help their children with homework," said Dr. Levi. "We focus on cognitive improvement as well as functional improvement, evaluating patients on day one and starting therapy within 24 hours whenever possible. Early intervention doesn't allow weakness to set in or advance, and I think we will continue to see more successful outcomes with this approach."

"Early mobilization helps critically ill patients recover faster. The more they move, the better they do," said Dr. David Prince, Assistant Professor (General Internal Medicine and Physical Medicine and Rehabilitation. "Our therapists work with the critical care nurses so patients recover their strength while receiving life-saving treatment in the ICU. This is a team effort and could not take place without all disciplines involved."

Members of the Montefiore Early Mobility ICU team.In the first three months of the program's implementation, more than 90% of ICU patients were mobilized. Adverse events were minimal and mild. Patients spent an average of one less day on the ventilator, and the frequency of performing tracheostomies on patients was reduced by fifty percent.

The Early Mobility Program has also had a positive effect on both patients and staff, according to Dr. Levi. "The physical conditioning has improved our patients' moods, and as they have felt better they have become more engaged in their care," she said.

"The EM program in our unit has energized our staff, our patients, and their families" agreed Melba Garcia, R.N., Administrative Nurse Manager for the MICU. "When they see other patients out of bed and moving, family members approach us and ask, ‘When will you start working with my mother?' This never happened before."

"Our early results have been very promising, and the entire MICU team is behind the project," said Dr. Eisen. "So far things are going smoothly, and patients and families are happier, which has helped us improve the MICU workplace and improve patient outcomes."

"By challenging our assumptions and changing the way we think, we have learned that early ICU rehabilitation is safe and well tolerated, improves functional status, and impacts quality of life. Our goal to discharge patients home is entirely attainable," said Dr. Levi, who is currently overseeing the expansion of this program to the Einstein campus, with plans to expand to the Wakefield campus "By altering our approach—from keeping ICU patients immobile to making them active participants in their own care—we have made a significant difference in improving their outcomes."